A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

Sit in a hot tub for 30 min every evening

Raise chairs to keep knees lower than hips

Use the arms to pick up heavy items

Perform pelvic rocking exercises several times per day

Answer and Explanation

The Correct Answer is D

Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.

Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.

Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.

Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.

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Correct Answer is A

Explanation

A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.

C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.

D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma B. Use a moisturizing soap to clean the skin around the client's stoma C. Empty the client's ostomy pouch before removing the skin barrier D. Change the client's ostomy appliance 1 hr after breakfast

Correct Answer is ["C"]

Explanation

A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.

B. Use a moisturizing soap to clean the skin around the client's stoma.Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.

C. Empty the client's ostomy pouch before removing the skin barrier.Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.

D. Change the client's ostomy appliance 1 hour after breakfast.Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.

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A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["C"]

Explanation

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